Ambulance Services and Records Requests
In case of an emergency call 911
Request for Records
To request non-medical records complete the records request form below and e-mail it to Fire@gjcity.org.
To request medical records complete the records request form below and fax it to (970)549-5840 or mail to
ATTN: Ambulance Services
625 Ute Ave.
Grand Junction, CO 81501
Fee: $.25 per sheet
Medical Record Requests: Parents may request information on behalf of their minor children. As well as a request on behalf of another adult can be processed with a notarized statement of consent from the patient to the requesting party.
- Attorney request for patient records can be processed with a notarized consent from the patient to the Attorney.
- All requests require a completed and signed record request form and a copy of your photo ID.
- Requests should be made at Fire Administration (625 Ute Avenue) if not made in person all signatures are required to be notarized.
| Office Address: | 625 Ute Avenue, Grand Junction, CO 81501 |
| Office Hours: | Monday - Friday, 8am to 5pm |
| Office Number: | 970-549-5830 |
| Office Fax: | 970-549-5840 |
| Non-Emergency Ambulance Dispatch: | 970-242-6707 |
| Sheldon Kier - Medical Services Chief | sheldonk@gjcity.org |
| Danni Ferguson - Finance Technician | dannif@gjcity.org |
| Billing Questions - Wittman Enterprises | 1-800-906-6552 |
Non-Emergency Transport Forms
- Advanced Beneficiary Notice (ABN)
- Hospice Payment Authorization Request
- Medicaid Authorization
- Patient/Guardian Consent to Release of Records
- Physician Certification Statement (PCS) for Medical Necessity
- Release of Medical Information for Billing Purposes
Needed Non-Emergency Transport Request Forms
- Non-Emergency Ambulance Transport Folder
- Physician’s Certification Statement (PCS) for Medical Necessity
- Patient Face Sheet
- Patient Medication List
- DNR Order (if patient has one)
Other Forms
Non-Emergency Ambulance Dispatch: 970-242-6707
* In case of an emergency call 911
